Thromboprophylaxis in adult and paediatric burn patients: A survey of practice in the United Kingdom.

INTRODUCTION: Patients with burn injuries are at an increased risk of venous thromboembolism (VTE). This predisposition is secondary to the endothelial injury, hyper-coagulable state and stasis (Virchow's triad) associated with burn injury. Although the true incidence of VTE in burn patients has not been adequately quantified, symptomatic VTE occurs in 0.2-7% of this population. VTE prophylaxis has proven clinical effectiveness and affords a reduction in the morbidity associated with such events, but the benefits and risk of complications need to be balanced in order to provide the best quality of care. Owing to the lack of prospective data on VTE in burns, practice varies greatly, not only internationally, but also between local burns services. Our aim was to better understand current VTE practice within United Kingdom (UK) burn care services by performing a comprehensive survey. METHODS: We contacted all the inpatient burn care services in the UK and collected data on current VTE practice via a standardised questionnaire. Services were given the choice to complete the survey by telephone or email and a follow-up plan was formulated. RESULTS: Twenty-five burn care services were contacted and 23 agreed to participate (92% response rate). Responding services treated adults, children or both and lead burn nurses or senior medical staff familiar with current VTE practice were interviewed. Routine VTE prophylaxis was provided in 84% of burn services and the majority utilised a combination of chemoprophylaxis and thromboembolic deterrent stockings (TEDS). All used low molecular weight heparin (LMWH) as their choice of chemoprophylaxis. Of those treating adults, all used a VTE prophylaxis protocol, but none of these applied to children. Only 56% of services treating children had such a protocol. The majority discontinued prophylaxis once patients were mobile. DISCUSSION AND CONCLUSION: Although the true burden of VTE in burn patients is unknown, we recognise that they are a population at risk. In addition to changes in the inflammatory and clotting pathways associated with thermal injury, prolonged hospital stay, ventilatory support, multiple surgeries, numerous central venous cannulations and reduced mobility all multiply this risk. The risk associated with the administration of heparin (bleeding complications and heparin-induced thrombocytopaenia) is low and can be reduced even further to 0.1% by the use of LMWH. The risk of symptomatic VTE is far greater, therefore the benefits of VTE prophylaxis would seem to outweigh the risks of not undertaking prophylactic measures. A higher LMWH dose and routine monitoring of anti-factor Xa levels are useful for acute burn patients. Two previous surveys, performed in Canada and the United States of America (USA), found routine administration of VTE prophylaxis to be 50% and 76% respectively. Of the 71 centres in the USA participating in the survey, 30% used a combination of sequential compression devices (SCD) and heparin and 24% did not provide VTE prophylaxis at all. A lack of prospective data on VTE in burn patients appears to be associated with diverse practice, and consensus on this topic could ensure that the potential morbidity caused by VTE is reduced. A clinical tool for identifying patients at risk and guidelines for management will standardise practice, which in turn should allow us to improve and maintain high quality care for burn patients.

Hydrotherapy in burn care: a survey of hydrotherapy practices in the UK and Ireland and literature review.

INTRODUCTION: Hydrotherapy is widely used in burns management however there are risks associated with its use, in particular cross-infection. Data regarding indications and techniques in common use is deficient. This study aimed to investigate hydrotherapy practices in the UK and Ireland. METHODS: A survey of the hydrotherapy practice of major burn care providers was performed by e mail and where necessary, follow up telephone contact. RESULTS: The survey included 28 burn care providers. 27 reported using hydrotherapy. Only 11 (41%) had defined indication criteria with 4 (15%) implementing a specific protocol. Variations in hydrotherapy practice were seen. CONCLUSION: Hydrotherapy is used nationwide, however considerable variation in practice exists. One area worthy of further consideration is the need for appropriate standards of infection control.

Acticoat dressings and major burns: systemic silver absorption.

Despite widespread use of wound dressings containing silver, few studies have investigated patients' serum silver levels. An earlier study of Acticoat use in small burns showed transient elevations of serum silver. The aim of this study was to examine the serum silver profile when Acticoat is used in major burns. A prospective study of 6 patients with burns greater than 20% total body surface area (TBSA). All burn wounds, including grafted and non-grafted areas and skin graft donor sites, were dressed with Acticoat or Acticoat Absorbent. Patients' serum silver levels, biochemistry and haematology were examined before, during and after the application of the silver dressings. The median total wound size (including donor sites) was 46.1% TBSA. The median maximum serum silver level recorded, 200.3 µg/L, reached at a median of 9.5 days following initial silver dressing application. This decreased to a median of 164.8 µg/L at the end of the treatment period and to a median of 8.2 µg/L at the end of follow-up. One adverse event, partial skin graft loss was thought to be dressing related. In this small study, serum silver levels were elevated but remained similar to that reported following the use of silver sulfadiazine. This study confirmed our view that Acticoat is safe to use on patients with burns, even when they are extensive.

Paediatric burns caused by other children.

OBJECTIVE: Children with burns inflicted by other children represent a small proportion of referrals to our paediatric burns unit. The aim of this paper is to investigate any differences between them. DESIGN: Prospective observational audit. PARTICIPANTS: Children admitted between January 1998 and December 2003. RESULTS: Forty-seven patients were admitted to our paediatric burns unit with burns inflicted by other children, of which 38 were male. Scalds were the cause of 53% of all the injuries. Two distinct groups were identified; one group had their burns inflicted by other children accidentally (Group A) and another reported their burns as inflicted by other children intentionally (Group B). The majority had less than 10% total body surface area (TBSA) burns sustained at home. Thirteen patients (27.7%) were reported as deliberate (Group B). The majority in Group B were males (90.9%, P>0.0001) with a median age of 12 years (P>0.0001) who sustained flame burns (P>0.0001) outdoors with a greater %TBSA (mean 12.1% versus 3.8% for Group A) and higher percentage of full thickness burns (38.5% versus 20.6% of group A). More children from Group B had separated parents (53.9% versus 5.9%) and came from poorer socioeconomic backgrounds (69.2% versus 8.8%). All the cases that required ITU admission came from this category. These patients required more surgery as compared to the accidental group (61.5% versus 26.4%). Children from Group B required prolonged periods of outpatient follow up (53.8% versus 14.7% from Group A) and a greater proportion of these children failed to keep outpatient follow-up appointments as compared to the accidental group (38.5% versus 23.5% of Group A, P=0.0007). CONCLUSION: Older male children sustained significant burns outside their homes. They reported them as being deliberate assaults, although on closer inspection of the circumstances it was difficult to support their account of the events.

The safety of nanocrystalline silver dressings on burns: a study of systemic silver absorption.

INTRODUCTION: Wound dressings containing silver have been in widespread use for many years. However, there are few quantitative data on the systemic absorption of silver or whether there is associated clinical risk. OBJECTIVES: To assess systemic silver levels when Acticoat dressings containing nanocrystalline silver were used, and to determine whether increases in such levels were associated with haematological or biochemical indicators of toxicity. METHOD: A prospective, single-centre, open-label study of 30 patients with relatively small burns that required skin grafting. Serum silver levels were measured before, during and at discontinuation of the use of the Acticoat dressings, and again at 3 and 6 months following completion of treatment. RESULTS: The median total postoperative wound size was 12% of the total body surface area. The median time to maximum silver levels was 9 days. The median maximum serum silver level was 56.8 microg/l. The median serum level at 6 months was 0.8 microg/l. There were no haematological or biochemical indicators of toxicity associated with the silver absorption observed in this study. CONCLUSION: This study has confirmed our view that Acticoat products are safe for use on burns and they remain a standard part of treatment at our centre.